Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
To prepare for the transition, facilities will want to confirm they are well educated on the facts about QAPI. Intimate knowledge of their Five STAR Quality Measures, become familiar with the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letters, and become fluent in critical thinking, process improvement and data-driven performance measures.
Engendering buy-in from key staff is crucial. Remember that QAPI is not intended to be a “one person show”, nor is it limited to line staff management. A successful QAPI program should impact and have participation from all levels of the facility team, from front-line staff to the Board of Directors. Harmony Healthcare International (HHI) recommends facilities educate all team members now, so they will be up to speed on the key concepts and principles of Performance Improvement. Remember that front-line staff may not have had a lot of experience with Performance Improvement. QAPI will unite all members of the team together to work for a common goal through Performance Improvement principles.
Additionally, facilities will want to assess the current QA program to determine how it will need to be restructured to meet the requirements of QAPI. Harmony Healthcare International (HHI) suggests decisions such as what process will be in place to develop the QAPI work plan, who will lead the program, and if a steering committee will be used to get the transition moving. Assess the current culture in the facility. For example, investigate if staff members feel comfortable bringing identified problems to the QA team. Consider factors such as how well staff members work in a team. Review the current process for determining the cause of a problem and consider if another, more formal Root Cause Analysis system should be in place. Harmony Healthcare International (HHI) suggests reviewing past projects that have been both successful and difficult - to determine what the facility’s strengths and weaknesses are.
The existing Quality Assessment and Assurance (QAA) provision at 42 CFR, Part 483.75(o) specifies the QAA committee composition and frequency of meetings in nursing facilities and requires facilities to develop and implement appropriate plans of action to correct identified quality deficiencies. This provision provides a rule but not the details as to the means and methods taken to implement the QAA regulations. CMS is now reinforcing the critical importance of how nursing facilities establish and maintain accountability for QAPI processes in order to sustain quality of care and quality of life for nursing home residents.
Click below to download a checklist of the tasks that should be completed to verify a comprehensive and effective QAPI Program is put in place by November 28, 2017.
Need additional training or a better understanding of QAPI? Join us for our upcoming QAPI Certification Courses (CHHi-QAPI). Click here to see the dates and locations.
6th Annual LTPAC Symposium
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